Read the Conversation

EF: What do you think 2023 holds for the healthcare scene in South Africa? 

IB: Currently, we are witnessing a major shape-shifting phenomenon driven by rapid growth and multiple initiatives aimed at providing low-cost coverage. This shift is being spearheaded by industry giants such as Dischem, Discovery, Mediclinic, and Intercare. It has become increasingly clear that offering a product for primary care services that encourage pre-funding and pre-saving, whether as individuals or employers, is crucial. This is the biggest trend we are seeing now. 

After three years, we are finally experiencing a full year of business operations, with the last complete year being 2019. It is a year of recovery for businesses, but the energy crisis has caused major disruptions in the economy, leading to rising unemployment and decreasing populations with formal health insurance. The upper end of the market has been negatively impacted by people leaving their jobs. However, there is a positive development in the form of dynamic growth in low-cost coverage for primary care that has entered the market. 

EF: What is your view on the current trend of pharmaceutical companies consolidating, specializing, and spinning off, and which companies do you aim to make an impact on? 

IB: In African markets, there is a growing need to develop private sector capacity to meet the unmet healthcare needs of the growing middle class. While South Africa is experiencing an economic contraction due to the energy crisis, the rest of the continent has a rapidly increasing population that is willing and able to self-fund their care. They are looking for affordable quality healthcare services and the government cannot invest fast enough to meet their needs. Private sector growth is the only solution. 

When people talk about self-funding care, they are primarily referring to primary care. This type of care does not require large hospitals but instead relies on SMEs like retail pharmacies that can provide accessible and affordable care to patients. Our focus is to help these businesses grow and develop to meet the increasing demand for healthcare services on the continent. While there are big developments happening, it is the private sector that is delivering healthcare services at scale and meeting patient needs through primary care SMEs. 

EF: What was the motivation behind starting Unjani Clinics, and how does it aim to change the focus from doctor-centred to nurse-centred care to provide affordable services for communities in need? 

IB: I spent ten years in medical practice. In private general practice in South Africa, two-thirds of the patients that were paying to see me did not need to see somebody with a seven-year degree. They needed somebody who was capable of managing and handling the conditions they had. Unless we move from doctor-centred care to nurse-centred or community health worker-centred care as our primary point of engagement, we are never going to develop the capacity to deliver for a population that has no services and to do it at a price point that is affordable for that community. 

We started Unjani Clinics in 2010 for the sole reason that we had to change the focus from doctor-centred care to nurse-centred care. The unit cost per engagement for a nurse practitioner is 17 percent of the unit cost of an engagement with a doctor. For the unit cost per engagement, the biggest driver is the income expectation of the professional delivering the service. If we have a laboratory system where every test must go to a central laboratory that is overseen by pathologists and managed by health techs and medical techs, we are going to have a very high unit cost of engagement. If we have a nurse practitioner using point-of-care diagnostic systems, there is a small capital cost to set up the units, but the run-on cost is a marginal addition to the individual patient. The engagement cost and the cost of laboratory services are completely different. 

If we are talking about disrupting cost, it is not about getting the medicines 10 percent cheaper. It is about completely transforming and disrupting the model of engagement. 

EF: What is the potential role of AI in expanding nurse capacity? 

IB: We can look at Hendri Hanekom’s business in telemedicine. In telemedicine, we need to think about business-to-business telemedicine and business-to-consumer telemedicine. 

Business-to-business telemedicine is where you have one practitioner coaching, guiding, and supporting another practitioner. Business-to-consumer telemedicine is where you have a practitioner engaging with a patient. I am a huge supporter of business-to-business telemedicine because it has massive potential for decentralizing skills and services and optimizing patient flows into points of referral. 

Business-to-consumer telemedicine is a dog show more challenging because the customer satisfaction level and the clinical engagement level can be poor. There is great utilization in the use of business-to-consumer telemedicine in a follow-up or with a patient that has been discharged and you are just checking in on. There is massive potential for cost reduction and simplification. 

AI for business-to-consumer is quite different. In terms of enhancing health literacy and enabling self-care, there is huge potential for the use of artificial intelligence. We have to be careful because, if you take the simple logic of large language models, there is no large language model available yet that has any indigenous languages or local vernacular. The ability for them to be fit for a place is a lot harder than being fit for purpose. 

The current large language models are great and fit for purpose in terms of achieving health education and enhancing health literacy, but they are not yet fit for a place in an African low-income setting. South Africa adopted sign language as its 12th official language this week. As an official language, it entitles hearing and speech-impaired people to an engagement point with hospital services. 

AI has massive potential. Large language models are not a science. A large language model takes a range of data and looks for patterns within that data, and it then derives an opinion based on those patterns. A lot of my professional colleagues from the medical field are against that because they believe that the patient is just getting an opinion and not a scientific fact. 

There is a difference between a large language model, which is an AI scenario, versus an algorithm, which is a binary yes or no-follow the path-get to a decision. A lot of people in the medical profession want us to use algorithms. 

When I was in the medical profession, I would listen to the patient's story. This was called a patient's history. I would then look at them to see what I could observe in terms of physical signs. I would also do one or two little tests to get some numbers on a piece of paper, and based on the pattern of those recordings, I formulated an opinion of what I thought was going on and managed that condition on a presumptive basis. This sounds like a large-language opinion model. Generally, the medical profession practices a large-language model in its approach to diagnosis and management. 

 EF: What are your thoughts about AI reducing the cost of intelligence? 

IB: Specialist radiologists who have undergone extensive training are incredibly valuable, but advancements in technology have allowed for even greater precision and efficiency in healthcare. Machines can analyze normal chest X-rays and determine which ones require a human opinion, and the more they are trained, the more accurate they become. Utilizing this technology can significantly reduce costs and improve access to medical services. 

While some radiologists may prefer to work in bustling cities, it is important to consider how to best serve patients in areas like Nelspruit. Artificial intelligence can be leveraged to enable remote access to medical expertise, and telemedicine can empower qualified professionals who are willing to live and work in these areas. By embracing these technologies, we can enhance access to healthcare and improve the quality of life for all. 

EF: What is your opinion on South Africa's progress in data management and utilization for decision-making at various levels? 

IB: Discovery’s emphasis on data, sophistication, and market influence is truly catalytic. If you want to excel in the health insurance sector in South Africa, you cannot ignore the impact of Discovery. 

South Africa's advancement in data management and decision-making is not by chance, but rather the result of a private player that has set the standard for data use and strategy. Other industry players must strive to emulate Discovery's approach to remain competitive. This private organization has effectively transformed the industry through its innovative strategies. 

Discovery's data has the potential to greatly benefit the National Health Insurance (NHI) scheme. 

EF: What advice would you give to executives who are looking to invest in creating a sustainable ecosystem in Africa? 

IB: I strongly believe in industry associations and their value, and I am currently working with the Federation of Associations of African Pharmaceutical Manufacturers (FAPMA). FAPMA needs funding for a secretariat and a conference to enable African manufacturers to engage with each other as an industry. This is essential because there is a lot of conversation around African manufacturing now, and empowering manufacturers to engage in that conversation is crucial. 

I am also enthusiastic about innovation in AMR financing and involved in a significant initiative around antimicrobial resistance. This initiative has the potential to demonstrate a new way of looking at health financing. For instance, the subscription model that the United Kingdom NHS uses to incentivize novel antibiotic research can be expanded to create a risk-pooling model that incorporates both antimicrobial stewardship and the supply of commodities. By doing so, it is possible to dislocate the transaction cost from the activity, which would allow us to create a capitated model for antimicrobial resistance programs. If we can figure out how to do that, we can apply the same model to diabetes and hypertension. This is why I am involved in antimicrobial resistance and stewardship because it could become a whole new way of looking at health financing. 

May 2023
South Africa